| NPI | 1912419706 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: FL DN22551) | 
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL 22551) | 
| 1223G0001X Dentist, General Practice (Licence: PA DS041458) | |
| Enumeration Date | 2017-11-01 | 
| Last Update Date | 2025-02-24 |